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General NPI Number Information
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NPI Number | 1629278197
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Entity Type | Individual
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Provider Name | KRISTINE ANNETTE LOPEZ LCSW
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Gender | Female
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Dates
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Enumeration Date | 07/23/2007
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Last Update Date | 08/10/2021
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Provider Practice Location Address
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Address Line | 111 N WASHINGTON ST STE 13
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City | MOSCOW
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State | ID
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Zip | 83843-2884
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Country | US
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Telephone | 208-596-4129
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Fax |
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Provider Business Mailing Address
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Address Line | 417 E VEATCH ST
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City | MOSCOW
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State | ID
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Zip | 83843-3570
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Country | US
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Telephone | 208-596-4129
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW35858
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I-04976
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License Number State | NM
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